Unfortunately, it’s the patient who is left out in the cold.
The American Rescue Plan Act (ARPA) extends eligibility for health insurance subsidies to people buying their own health coverage through the Patient Protection and Affordable Care Act (PPACA) federal Marketplace who have incomes over 400 percent of the federal poverty level. It also increases the amount of financial assistance for people at lower incomes who were already eligible for PPACA coverage. This change will only last two years, at a cost of around $62 billion.
While extending benefits, it still does not solve the problems of high co-insurance amounts and lack of access.
First, let’s take some real-life examples of how high deductible amounts impact insurance coverage under the PPACA. Bob is a mechanic working in Florida. Like millions of Americans, Bob takes blood thinners for recurring blood clots. One of Bob’s reasons for signing up for healthcare coverage was to cover the $492 per month he had been paying for Eliquis for the last eight years.
When Bob signed up through the Marketplace, he thought he would have to pay a deductible, but that most of the cost of the drug would be covered by his policy. Bob was stunned when he went to the pharmacy only to be told that his prescription still costs $492, because the cost was being applied to his deductible of $6,000.
Bob had another painful surprise coming when he decided to go to the doctor for a persistent cough. He looked to see where his closest physician was who was part of his plan. He found the doctor’s office, 18 miles from where he lived. Considering traffic, that was around an hourlong drive. This is because, either intentionally or unintentionally, there are no participating primary care providers closer to Bob. It may make sense that it may be hard for a plan to cover all the bases with specialty care. But many PPACA plan beneficiaries can’t find primary care providers nearby.
From a monetary position, if plans collect premiums and do not have to provide care, PPACA plans can become much more profitable. The plans benefit from forcing enrollees to pay for their own care.
Patients enrolled in insurance plans are increasingly forgoing services because of the high deductible amounts. Insurance plans benefit by collecting premiums as patients forego services when they can’t afford deductibles. Providers are raking in cash when they get paid at full charges when patients have to pay high deductibles. It is the patient who is left out in the cold.
This is a terrible system. The worst of it is that patients are often foregoing lifesaving care they need because they can’t afford their deductibles and coinsurance amounts. Let’s change the system.
Programming Note: Listen to live reports from Timothy Powell every Tuesday on Talk Ten Tuesdays, 10 Eastern.
I want to cover a story that was spectacularly overshadowed by the recent assassination of former CEO for UnitedHealthcare Brian Thompson. The story is the
It’s been an interesting week in corporate healthcare. But I want to start with some context. First, it’s important to recognize that the purpose of
Please log in to your account to comment on this article.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
